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AetnaAll Plans · Coverage · Medical Policy · Pediatrics, Family MedicineMedium impact

Rotavirus Vaccine (CPB 0723, reviewed 2025-11-25)

Effective date
Not stated in the notice
Identified
Aug 16, 2026

Summary

Aetna considers the FDA-approved rotavirus vaccines RotaTeq and Rotarix medically necessary for prevention of rotavirus gastroenteritis in infants less than 8 months of age, based on Centers for Disease Control and Prevention Advisory Committee on Immunization Practices recommendations. Rotavirus vaccines are considered experimental, investigational or unproven for all other indications because their effectiveness for those indications has not been established.

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What to do

Action · 3 steps
01Billing team: Bill CPT 90680 (RV5, 3-dose schedule) and CPT 90681 (RV1, 2-dose schedule), with ICD-10 Z23, only when the selection criteria are met.
02Confirm the dose timing: for RotaTeq, the first dose is given at 6 to 12 weeks of age, later doses are given 4 to 10 weeks apart, and the third dose is not given after 32 weeks of age; for Rotarix, the first dose is given from 6 weeks of age and the second dose is given at least 4 weeks after the first and before 24 weeks of age.
03Check the member's benefit plan description, because some plans exclude coverage of preventive services.

Codes mentioned

9068090681Z23

Original notice

Rotavirus Vaccine (CPB 0723, reviewed 2025-11-25)
aetna.com · Always check the source before changing claims.
View original ↗

Related changes

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Related policy hubs

Aetna policiesPediatricsFamily MedicineCode 90680Code 90681Code Z23

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